=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851007132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLIVINE, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2023
-----------------------------------------------------
Last Update Date | 01/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7137 236TH AVE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53168-8975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-800-4672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10278 COOPER RD
-----------------------------------------------------
City | PLEASANT PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53158-6524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-705-3238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/INCORPORATOR
-----------------------------------------------------
Name | ANDREA VALERI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 262-705-3238
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------